Subscribe to this blog

Get GeriPal Email Updates

Search This Blog

Outcomes of Surgery in Older Persons: How Could We Know So Little?

About half of all operations performed in the United States are performed on persons over the age of 65. So you would think that there would be tons of research to help us guide patients as they ask us questions about how their health will be impacted by an operation. But we know very little. As far as evidence-based medicine is concerned, surgery in the elderly is an evidence-based wasteland.

How will an 85 year old with severe knee arthritis do after a joint replacement? One reason that this question is so hard to answer is that 85 year olds are so different. This question can not be answered generically. Some are highly active, while others (even if they had good knees) are disabled physically and/or cognitively. We suspect functional factors like these are likely to have huge impacts on surgical outcomes, but there is almost no data to guide us.

And we even lack the most basic evidence to address the older patient's "How will I do after surgery" question. Most of the information we have is on rates of death and surgical complications such as post-operative pneumonia. Of course these are important, but when the older patient asks, "how will I do" often what they are really asking is "How long will it be before I get back to normal?" "How long will I have trouble taking care of myself and be dependent on family caregivers?" "How long will my thinking be abnormal after surgery?" "How long before I can climb up the flight of stairs to my home?" "I know death is a rare complication, but how often will I suffer a permament loss in my ability to function independently?"

The honest answer to these questions: "WE DON'T KNOW."

In the New Old Age blog, Paula Span reports on an important study that breaks useful ground in starting to address these important questions. Led by Dr. Martin Makary, a surgeon at Johns Hopkins Hospital, the study proves that easy to measure markers of the patient's functional status strongly predict outcomes after surgery in older patients.

Markary used a 5 item frailty score (Weight loss, poor grip strength, exhaustion, low physical activity, decreased walking speed). The number of these measures on which a patient was frail strongly predicted outcomes after surgery. In fact, the frailty score seemed to be a better measure of surgical risk than the age of the patient or standard measures of surgical risk. The frailty score strongly predicted the risk of post-operative complications, or the need for nursing home care after surgery.

This study is a very useful advance in our understanding of surgical outcomes in older persons, but there is a need for much more research. Further studies need to better refine which measures of patient functioning best predict surgical outcomes. For example, this study did not measure cognitive functioning, which is undoubtedly a very important determinant of outcomes.

More importantly, while this study showed that it is important to assess functional ability before surgery, we need to know more about what happens to functional ability after surgery. This study advanced our understanding of commonly used surgical outcomes, but did not look at functional status outcomes. (ie, how long will my caregiver need to help with basic activities of daily living? How long before my walking is back to normal?)

We need studies in older persons that really provide an answer when the patient asks, "How will I do after surgery?"

Hopefully this study is the first of many from this team that begin to address these vital questions.

by: [Ken Covinsky]

Get link

Facebook

Twitter

Pinterest

Email

Other Apps

Get link

Facebook

Twitter

Pinterest

Email

Other Apps

Comments

It's been my experience (professionally and personally) that much more is known than communicated (to patients and/or families).It's been the slow rate of adoption of evidence-based practices, coupled with poor clinician-patient communications, which need to be improved.

Popular posts from this blog

My colleagues often ask me: “Why are Chinese patients so resistant to hospice and palliative care?” “Why are they so unrealistic?” “Don’t they understand that death is part of life?” “Is it true that with Chinese patients you cannot discuss advance directives?”

As a Chinese speaking geriatrician and palliative care physician practicing in Flushing, NY, I have cared for countless Chinese patients with serious illnesses or at end of life. Invariably, when Chinese patients or families see me, they ask me if I speak Chinese. When I reply “I do” in Mandarin, the relief and instant trust I see on their faces make my day meaningful and worthwhile.

At my hospital, the patient population is about 30% Asian, with the majority of these being Chinese. Most of these patients require language interpretation. It becomes an interesting challenge and opportunity, as we often need to discuss advance directives, goals of care, and end of life care options…

In this week's GeriPal podcast we discuss delirium, with a focus on prevention. We are joined by internationally acclaimed delirium researcher Sharon Inouye, MD, MPH. Dr Inouye is Professor of Medicine at Harvard Medical School and Director of the Aging Brain Center in the Institute for Aging Research at Hebrew SeniorLife.

Dr. Inouye's research focuses on delirium and functional decline in hospitalized older patients, resulting in more than 200 peer-reviewed original articles to date. She has developed and validated a widely used tool to identify delirium called the Confusion Assessment Method (CAM), and she founded the Hospital Elder Life Program (HELP) to prevent delirium in hospitalized patients.

We are also joined by guest host Lindsey Haddock, MD, a geriatrics fellow at UCSF who asks a great question about how to implement a HELP program, or aspects of the program, in a hospital with limited resources.

Estimating prognosis is hard and clinicians get very little training on how to do it. Maybe that is one of the reasons that clinicians are more likely to be optimistic and tend to overestimate patient survival by a factor of between 3 and 5. The question is, aren't we better as palliative care clinicians than others in estimating prognosis? This is part of our training and we do it daily. We got to be better, right?

Big findings from this JPSM paper include that we, like all other clinicians, are an optimistic bunch and that it actually does impact outcomes. In particular, the people whose survival was overestimated by a palliative care c…

GeriPal (Geriatrics and Palliative care) is a forum for discourse, recent news and research, and freethinking commentary. Our objectives are: 1) to create an online community of interdisciplinary providers interested in geriatrics or palliative care; 2) to provide an open forum for the exchange of ideas and disruptive commentary that changes clinical practice and health care policy; and 3) to change the world.

No confidential patient information should be placed on GeriPal, nor should any confidential information be placed in the comments. The information provided on GeriPal is designed to complement, not replace, the relationship between a patient and and his/her own medical providers. The editors (Alex Smith and Eric Widera) reserve the right to remove comments that are deemed inappropriate due to the commercial, abusive, or offensive nature of a comment. If you think your comment was deleted for inappropriate reasons, please email either Alex or Eric.

GeriPal's mission is to improve the disemination of information in both geriatics and palliative medicine. GeriPal was created with the support of the Division of Geriatrics at the University of California San Francisco. Its content though is strictly the work of its authors and has no affiliation with or support from any organization or institution. All opinions expressed on this website are solely those of its authors & do not reflect the opinions of any academic institution or medical center. This web site does not accept advertisements. All email addresses collected by GeriPal for feed distribution will be kept confidential and will never be used for commercial reasons. If you reproduce the material on the website please cite appropriately. For questions regarding the site please email Alex Smith, MD (aksmith@ucsf.edu) or Eric Widera, MD (eric.widera@ucsf.edu)